James Davis

Subcortical and Cortical Structural Central Nervous System Changes and Attention Processing Deficits in Preschool-Aged Children with Prenatal Methamphetamine and Tobacco Exposure

Objective: To examine the independent contributions of prenatal methamphetamine exposure (PME) and prenatal tobacco exposure (PTE) on brain morphology among a sample of nonalcohol-exposed 3- to 5-year-old children followed prospectively since birth. Study Design: The sample included 20 children with PME (19 with PTE) and 15 comparison children (7 with PTE), matched on race, birth weight, maternal education and type of insurance. Subcortical and cortical volumes and cortical thickness measures were derived through an automated segmentation procedure from T1-weighted structural magnetic resonance images obtained on unsedated children. Attention was assessed using the computerized Conners’ Kiddie Continuous Performance Test Version 5 (K-CPT™ V.5). PME effects on subcortical and cortical brain volumes and cortical thickness were tested by general linear model with type III sum of squares, adjusting for PTE, prenatal marijuana exposure, age at time of scan, gender, handedness, pulse sequence and total intracranial volume (for volumetric outcomes). A similar analysis was done for PTE effects on subcortical and cortical brain volumes and thickness, adjusting for PME and the above covariates. Results: Children with PME had significantly reduced caudate nucleus volumes and cortical thickness increases in perisylvian and orbital-frontal cortices. In contrast, children with PTE showed cortical thinning in perisylvian and lateral occipital cortices and volumetric increases in frontal regions and decreases in anterior cingulate. PME was positively related and caudate volume was inversely related to K-CPT reaction time by inter-stimulus interval, a measure of the ability to adjust to changing task demands, suggesting that children with PME may have subtle attentional deficits mediated by caudate volume reductions. Conclusions: Our results suggest that PME and PTE may have distinct differential cortical effects on the developing central nervous system. Additionally, PME may be associated with subtle deficits in attention mediated by caudate volume reductions.

Low health literacy and cancer screening among Chinese Americans in California: a cross-sectional analysis.

Objectives Cancer is the leading cause of death among Asian Americans. Chinese Americans comprise the largest Asian American ethnic group. Low health literacy (LHL) is associated with lower cancer screening rates, but this association has not been studied in Chinese Americans. We examined the relationship between LHL and meeting US Preventive Service Task Force (USPSTF) guidelines for cervical, colorectal and breast cancer screening among Chinese Americans. Design Observational study of Chinese respondents in the 2007 California Health Interview Survey, a population-based survey. Interview languages included English, Cantonese and Mandarin. Setting California, USA Participants Chinese respondents in age/gender groupings appropriate for USPSTF cancer screening guidelines (cervical: women ages 21–65, n=632; colorectal: men or women ages 50–75, n=488; and breast: women ages 50–74, n=326). Outcomes Relationships were tested using multivariable logistic regression models controlling for healthcare access and demographic factors, including limited English proficiency (LEP). The combined effects of having both LHL and LEP were specifically examined. LHL was measured by 2-items on perceived ease-of-use of written medical materials. All study variables were self-reported. Results Cancer screening percentages among Chinese Americans were 77.8% for cervical, 50.9% for colorectal (47.9% for women and 54.2% for men), and 85.5% for breast. LHL was associated with lower odds of meeting breast cancer screening guidelines (OR 0.41; 95% CI 0.20 to 0.82). Respondents with both LHL and LEP were significantly less likely to have up-to-date colorectal (OR 0.49; 95% CI 0.25 to 0.97) and breast cancer screening (OR 0.21; 95% CI 0.08 to 0.54) than those with neither health communication barrier. In all multivariable models, having seen a physician in the past year was a significant predictor of an up-to-date screening. Conclusions In Chinese Americans, LHL and LEP were negatively associated with up-to-date breast and colorectal cancer screening, independent of a recent physician visit. Efforts to promote cancer screening among Chinese Americans should consider and address LHL, LEP and physician access barriers.

Colorectal Cancer Screening: Low Health Literacy and Limited English Proficiency Among Asians and Whites in California

The authors examined the relationship between low health literacy (LHL), limited English proficiency (LEP), and meeting current U.S. Preventive Service Task Force colorectal cancer (CRC) screening guidelines for Asians and Whites in California. For 1,478 Asian and 14,410 White respondents 50–75 years of age in the 2007 California Health Interview Survey, the authors examined meeting CRC screening guidelines using multivariable logistic models by LEP and LHL separately and in combination. Analyses were run with the full sample, then separately for Whites and Asians controlling for demographics and insurance. For those with LEP, patient-provider language concordance and CRC screening was examined. Overall, respondents with LEP and LHL were the least likely to meet CRC screening guidelines (36%) followed by LEP-only (45%), LHL-only (51%), and those with neither LHL nor LEP (59%), a hierarchy that remained significant in multivariable models. For Whites, LHL-only was associated with screening, whereas LEP-only and LEP and LHL were significant for Asians. Having a language concordant provider was not significantly associated with CRC screening among those with LEP. Health literacy is associated with CRC screening, but English proficiency is also critical to consider. Asians with both LEP and LHL appear particularly vulnerable to cancer screening disparities.

Systemic and Placental Leptin and Its Receptors in Pregnancies Associated With Obesity

This study aimed to gain new insights into both systemic and placental leptin and its receptors, with reference to the maternal prepregnancy body mass index (BMI). Thus, 84 women (29 lean, 24 overweight, and 31 obese) were recruited and maternal, cord blood, and placental tissues collected prior to term labor. Plasma levels were measured by enzyme-linked immunosorbent assay and for placenta, immunohistochemistry and messenger RNAs (mRNAs) were quantitated. We confirmed that maternal leptin increased linearly as the soluble receptor decreased with BMI (P = .001). Fetal leptin increased with maternal BMI (P = .02) and birth weight (P = .006) and was higher in female infants (P < .001). Placental mRNA levels of leptin and its receptors showed no change in BMI. However, we show a significant (P = .043) linear increase in leptin in the placental vascular endothelial cells with maternal obesity, while leptin in syncytiotrophoblast showed no statistical change. Leptin receptors localized to syncytiotrophoblast and intravillous macrophages and were unchanged with BMI.

Adjustments to diabetes medications in response to increases in hemoglobin a1c: an epidemiologic study.

Objective: The primary objective was to assess associations between increases in glycated hemoglobin (HbA1c) levels and medication adjustments among patients with diabetes. A secondary objective was to measure the effect of adjustments on subsequent HbA1c levels. Methods: A retrospective analysis of administrative data from a large health insurer in Hawaii of 7654 patients with diabetes mellitus type II, HbA1c levels greater than 7%, and who were taking oral diabetic medications. Patients were eligible if they had an HbA1c measurement in 2009, a prior measure 30 or more days previously, and at least 30 days of follow-up to identify medication adjustments. Patients were classified into 3 groups based on their extent of change in HbA1c levels. Patients were followed to determine the frequency of medication adjustments and to observe the possible benefit of making adjustments on subsequent HbA1c levels. Results: Medication adjustments were the exception, occurring among less than a fourth of patients. Compared with patients without HbA1c increases, patients with <1% HbA1c increases made adjustments 20% more frequently, and patients with increased HbA1c levels of 1% or more made adjustments 60% more frequently. Patients with similar HbA1c increases were more likely to adjust their medications if they had higher baseline HbA1c levels. Medication adjustments were mostly for oral diabetes medications; insulin use was seldom initiated, and then primarily by patients with HbA1c levels of 9% or higher. Patients with medication adjustments averaged about 0.40% lower HbA1c levels when reassessed after 120 days or more. Conclusion: The results show limited responsiveness to increases in HbA1c levels and a low initiation rate of insulin use. Patients adjusting their medications, however, had clinically significant improvements in their HbA1c levels. Clinical inertia and patient concerns are discussed as factors possibly limiting the frequency of medication adjustments.

Factors Associated with Place of Death for Elderly Japanese-American Men: The Honolulu Heart Program and Honolulu-Asia Aging Study

Place of death is an indicator of health service utilization at the end of life and differs according to cause of death. Asian Americans may have a higher percentage of hospital deaths than Caucasian Americans, yet reasons for this finding are unclear. This study examined distribution of place of death and the associations between place and cause of death in elderly Japanese‐American men in a longitudinal cohort: the Honolulu Heart Program and Honolulu‐Asia Aging Study. Data collected between 1991 and 1999 on 1,352 men aged 73 to 99 at death were analyzed for associations between cause‐of‐death characteristics and hospital, home, or nursing home location of death. Fifty‐nine percent of men died in hospitals, 23% died at home, and 18% died in nursing homes. Of the dementia‐related deaths, 43% occurred in hospitals (vs 16% in a national study), 37% occurred in nursing homes (vs 67% in a national study), and 20% occurred at home. Of the stroke deaths, 53% occurred in hospitals, 40% were in nursing homes, and 7% occurred at home. Of the cancer deaths, 53% occurred in hospitals, 34% occurred at home, and 13% were in nursing homes. Traditional family obligation to care for elderly people at home and inability to access care for dementia may account for the greater rate of hospital death and lower rate of nursing home deaths in this cohort. Attitudes of elderly Japanese Americans and their families regarding place of care at the end of life, particularly in the setting of dementia, merit future study.

Incident neuropathy in HIV-infected patients on HAART.

We determined the incidence of and risk factors for distal sensory polyneuropathy (DSP) in individuals on HAART. Sixty-one HIV-positive subjects on HAART for at least 6 months and neuropathy free were retrospectively selected. The study included subjects who had previously tolerated d-drugs without developing DSP. Neuropathy incidence over 4 years was calculated. Cox proportional hazards models were used to determine risk factors associated with incident DSP. Nineteen subjects developed DSP over a mean follow-up of 2.4 years. Subjects never treated with a d-drug developed DSP at a rate of 21 cases per 100 person-years (95% CI, 8.9-33.7). Subjects with a history of d-drug treatment but not on a d-drug at enrollment developed DSP at a rate of 17 cases per 100 person-years (95% CI, 2.1-31.8). Those on d-drug treatment developed DSP at a rate of 25 cases per 100 person-years (95% CI, 8.7-41.6). Multivariable analysis identified age [hazard ratio (HR) = 1.09; p < 0.01] and low CD4(+) nadir [hazard ratio (HR) = 0.79; p = 0.03] as significant risk factors. Current or prior history of treatment with d-drug was not a significant risk factor for incident DSP in subjects who had previously tolerated d-drug treatment without developing a toxic DSP. Age and low CD4(+) are risk factors for incident DSP. However, current or prior history of d-drug treatment is not a significant risk factor for incident DSP in subjects who had previously tolerated d-drug treatment without developing a toxic DSP.

Factors Affecting Sustained Medication Adherence and Its Impact on Health Care Utilization in Patients with Diabetes.

To identify factors associated with years of medication adherence and to examine the relationship between years of adherence and healthcare utilization.

Visfatin/Nampt and SIRT1: Roles in Postterm Delivery in Pregnancies Associated With Obesity.

Visfatin is both a systemic adipocytokine and the cytosolic enzyme, nicotinamide phosphoribosyl transferase (Nampt). This is a longevity protein, which extends the lifespan of human cells by activating sirtuin 1 (SIRT1). In this study, we sought a role for these proteins in obese pregnant women, who experience more postterm deliveries. Thus, 78 women (26 lean, 24 overweight, and 28 obese) were recruited and maternal blood and placental tissue collected prior to term labor. Plasma levels were measured by enzyme-linked immunosorbent assay and quantitative immunohistochemistry used for placenta. We confirmed maternal plasma interleukin 6 increased according to prepregnancy body mass index (BMI; P < .0001) and showed a linear relationship between BMI and syncytiotrophoblast visfatin/Nampt (P = .021) but not with its levels in maternal plasma. Both systemic and placental visfatin/Nampt were significantly associated with placental SIRT1 levels (P = .028 and .017). Thus, higher visfatin/Nampt may prevent a labor-associated decrease in SIRT1 leading to postterm delivery in obesity.

The LAST guidelines in clinical practice: implementing recommendations for p16 use.

OBJECTIVES To determine the impact of implementing p16 Lower Anogenital Squamous Terminology Standardization Project for HPV-Associated Lesions (LAST) guidelines, we compared p16 use and follow-up data before and after implementation of the guidelines. METHODS We reviewed all cervical biopsy specimens diagnosed by two pathologists before and after implementation of the LAST guidelines and calculated the rate of and reason for p16 use across all biopsy specimens, high-grade squamous intraepithelial lesion (HSIL) detection, and follow-up. RESULTS In total, 1,829 and 1,623 cervical biopsy specimens were reviewed in periods A and B, respectively. Overall p16 use increased from 2.8% to 6.2% (P < .001). Recommendations 2 and 4 increased from 0.16% and 0% of all cervical biopsy specimens in period A to 1.4% and 1.9% in period B, respectively (P < .0001). p16+ HSIL increased from 1.4% to 2.3% (P < .05). The positive predictive value of p16+ HSIL increased from 48% to 76% (P < .05). CONCLUSIONS Implementation of the p16 LAST guidelines resulted in a significant increase in p16 use and a significant increase in the positive predictive value of p16+ HSIL.